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By T. Kent. Pacific College of Oriental Medicine. 2019.
At the beginning of the session students will be asked to elect programme representatives generic warfarin 2 mg otc, the representatives can raise issues of general concern on behalf of their class discount 5mg warfarin otc. However all students should feel free to approach staff at any time throughout a session. The overall aim is to identify, at both local and national level, areas where improvements could be made and efforts targeted to further enhance the provision of taught degree programmes. A high response rate is necessary to obtain robust results, so participation is very important and would be greatly appreciated. They are able to raise concerns and issues which they may feel may be relevant to this Committee. Representatives are also welcome to participate in the Edinburgh University Students’ Association. Graduation All students intending to graduate must register by completing an online graduation registration form. The form should be submitted as soon as possible, but no later than 3 weeks before your ceremony. Any form submitted after this deadline will not be processed and graduation will be deferred until the next appropriate set of ceremonies. A registration fee of £40 is payable on first graduation from The University of Edinburgh in respect of life membership of the General Council, the statutory body comprising all of the University’s graduates. Students who, for any reason, do not wish to attend a ceremony (graduate in absentia) may do so but must still complete an online graduation registration form in order to receive their award certificate. Please be aware that if it is your intention to graduate at the above ceremony, any outstanding debts to the University must be paid to the Finance Office 21 days prior to the Graduation Ceremony. The Disability Office can assess your requirements and request adjustments and support you may need or negotiate specific assessment and exam arrangements. Assessment will be through an online journal review and basic statistics multiple choice questions. Online assessment (participation in interactive modules, discussion boards and group work) will constitute the other 10% of the overall course grade and is taken to represent a formative assessment of learning throughout the programme. The discursive paper will cover unusual clinical scenarios, difficult patient consultations and aspects of good and bad communication, possibly involving video clips. Online assessment through discussion boards and group work (wikis) will constitute the other 10% of the overall course grade and is taken to represent an assessment of learning throughout the programme. Online assessment through discussion boards and group work (wikis) will constitute the other 30% of the overall course grade and is taken to represent a formative assessment of learning throughout the programme (more details in programme proposal document). This is a written assignment critically reviewing a specific current global health problem. Online assessment in the form of discussion boards/ tutorials and group work and participation will constitute the other 50% of the overall course grade. This is taken to represent a formative assessment of learning throughout the programme. The written assignment should review aspects of palliative care management and should be considered in a specific clinical scenario. Summative works will be approximately 3,000 words in total and will be approved by the Health Informatics Programme Committee, on the recommendation of the Course Convener. This will be a reflective piece of around 2,000-2,500 words entitled, for example: "Take a learning outcome from your own clinical area and discuss how you would teach, assess and evaluate it; explaining and justifying the reason for your choices". This will be a written case assignment based on a particular patient- focused ethical situation and submitted online. Discussion boards and tutorial contributions will constitute the other 30% of the overall course grade which is also taken to represent a formative assessment of learning throughout the programme. Online assessment through participation in discussion boards, group work (wikis) and interactive materials will constitute the other 10% of the overall course grade and is taken to represent a formative assessment of learning throughout the programme. Within each specialty module students will be assessed by means of: Critical appraisal of recent journal articles (50%) through a combination of online journal clubs and written online journal article appraisal forms. Students will be encouraged to produce either a short PowerPoint presentation, podcast or audio lecture that can be put online for peer and tutor assessment. This piece should be written in a style appropriate for a general medical (non-specialist) audience. The formatting should be suitable for formal publication and should contain an appropriate review of the literature. Tutors and fellow students will grade presentations with marks allocated in a 60% (tutor) to 40% (student) ratio. Writing skills, awareness of issues relating to plagiarism and referencing will be introduced. Students will be expected to actively use these tools throughout the course to create pieces of solo and group work, for example making presentations, reviewing journal articles and writing short review articles.
Child > 12 years Child < 2 years Child 2-12 years and adult 1 part of 25% lotion 1 part of 25% lotion Undiluted Preparation + + 25% lotion 3 parts of water 1 part of water 12 hours (6 hours Contact time 24 hours 24 hours in children < 6 months) – Apply the lotion to the whole body purchase 2mg warfarin mastercard, including scalp order 2 mg warfarin overnight delivery, postauricular areas, palms and soles. Contra-indications, adverse effects, precautions – Do not apply to broken or infected skin. In the event of secondary bacterial infection, administer an appropriate local (antiseptic) and/or systemic (antibiotic) treatment 24 to 48 hours before applying benzyl benzoate. In case of ingestion: do not induce vomiting, do not perform gastric lavage; administer activated charcoal. Remarks – Close contacts should be treated at the same time regardless of whether they have symptoms or not. The treatment may be repeated if specific scabies lesions (scabious burrows) are still present after 3 weeks. Remarks – Storage: below 25°C – Once diluted, the solution must be used immediately; do not store the diluted solution (risk of contamination). Therapeutic action – Antiseptic Indications – Antisepsis of umbilical cord in maternity units Presentation – 7. Remarks – Storage: below 25°C – Once open, the mouthwash solution keeps for 4 weeks maximum. Clean medical surfaces, beds, surfaces, equipment Corpses, excreta, devices, equipment, ustensils contaminated with boots surfaces and linen in case of cholera blood and other body in case of cholera (after cleaning) (after cleaning) fluids spills (before cleaning) Concentration 0. Duration – 2 to 4 weeks Contra-indications, adverse effects, precautions – May cause: headache, local skin eruption or pruritus. Dosage and duration – 500 mg vaginal tablet Adult: one vaginal tablet as a single dose, at bedtime – 100 mg vaginal tablet Adult: one vaginal tablet/day for 6 days, at bedtime Contra-indications, adverse effects, precautions – May cause: local irritation; allergic reactions. At least 6 hours must have elapsed since the last administration of dinoprostone before oxytocin can be given. The % w/w is not equal to the % v/v because the mixture of water and alcohol produces a reduction in volume. For example: 40% v/v = 70° proof (British system) = 80° proof (American system) = 40° in French speaking countries. Preparation – Use 70% v/v ethanol, which is more effective than higher concentrations. To obtain 1 litre of 70% v/v ethanol: • take 785 ml of 90% v/v ethanol, or 730 ml of 95% v/v ethanol, or 707 ml of 99% v/v ethanol; • add distilled or filtered water to make up a volume of 1 litre; • leave to cool and top up with water again to bring the volume back to 1 litre (mixing water and ethanol together produces a reaction whereby volume is reduced). Precautions – Do not apply to mucous membranes, wounds or burns: it is painful, irritating and slows the healing process. Remarks – Ethanol can be used for disinfection of non-critical medical items (items that are in contact with intact skin only) that are not soiled by blood or other body fluids. Contra-indications, adverse effects, precautions – May cause: local allergic reaction (rare). However, preferably use the cream on moist lesions and the ointment on dry and scaly lesions. Contra-indications, adverse effects, precautions – Use with caution and under medical supervision in children under 2 years. The first signs of poisoning after accidental ingestion are gastrointestinal disturbances (vomiting, diarrhoea). Preventive treatment of non- infected persons is ineffective and increases the risk of resistance. As a precaution, this product should not be used in humans if an alternative is available. Therapeutic action – Antifungal, weak antiseptic, drying agent Indications – Oropharyngeal candidiasis, mammary candidiasis in nursing mothers – Certain wet skin lesions (impetigo, dermatophytosis oozing lesions) Presentation – Powder to be dissolved Preparation – Dissolve 2. Use – 2 applications/day for a few days Contra-indications, adverse effects, precautions – Do not apply to wounds or ulcerations. In the event of mammary candidiasis, clean the breast before nursing and apply cream after nursing. Remarks – For the treatment of vulvovaginal candidiasis, miconazole cream may complement, but does not replace, treatment with clotrimazole or nystatin vaginal tablets. Therapeutic action – Antibacterial Indications – localized non bullous impetigo (less than 5 lesions in a single area) Presentation – 2% ointment, tube Dosage and duration – Child and adult: 3 applications/day for 7 days, to clean and dry skin The patient should be reassessed after 3 days. Contra-indications, adverse effects, precautions – May cause: pruritus and burning sensation; allergic reactions. Contra-indications, adverse effects, precautions – Use with caution and under medical supervision in children under 6 months. Preventive treatment of non- infected persons is ineffective and increases the risk of resistance. Contra-indications, adverse effects, precautions – Do not use in children under 2 months (safety not established). In the event of secondary bacterial infection, administer an appropriate local (antiseptic) and/or systemic (antibiotic) treatment 24 to 48 hours before applying permethrin.
When the same results were presented first in terms of death and then in terms of life cheap warfarin 1 mg line, about one quarter of the study subjects changed their mind about their preference quality 1 mg warfarin. To avoid confusion associated with use of either percentages or framing biases, using comparisons can be helpful. For example, if a patient is considering whether to proceed with a mammogram, using a statement such as “The effect of yearly screening is about the same as driving 300 fewer miles per year” is helpful, if known. This puts the risk into per- spective with a common daily risk of living and helps the patient put it into per- spective. We will discuss this further when talking about quantifying patient val- ues in Chapter 30. Recommendations about providing the evidence The most important recommendation is to avoid overwhelming the patient with too much information. The key to avoiding this pitfall is to repeatedly check with the patient before and during delivery of the information to find out how much she understands. Using verbal terms such as “usually” instead of numbers is less precise, and may give unintended meaning to the information. When numbers are used as part of the discussion present them in natural frequencies rather than percents. To avoid the framing bias, results should be presented in both positive and neg- ative terms. For our example patient who is interested in aspirin to prevent heart attacks and strokes, it may be most practical to use multiple modalities for pre- senting information including verbal and pictorial presentations, presenting the evidence in this way: “In a large study of women like you who took aspirin for 10 years, there was no difference in number of heart attacks between patients who took aspirin and those who didn’t. In that study, 1 out of 1000 women experienced excessive bleeding from the aspirin. If one has a strong belief that one option is the best for the patient, state that with an explicit discussion of the evidence and how the Communicating evidence to patients 207 option best fits with the patient’s values. When the evidence is less than robust from weak study designs or because there are no known studies available, you cannot give strong evidence-based recommendations and must mitigate this by presenting options. When the evidence is stronger, present a recommendation and explain how that recommendation may meet the patient’s goals. In all cases, the physician has to be careful about differentiating evidence-based recommendations from those generated from personal experiences or biases regarding treatment. For our patient interested in aspirin for prevention of strokes and heart attacks, we might say: “While I understand it has been hard to lose weight and reduce your cholesterol, taking an aspirin won’t help you prevent heart attacks and is only very minimally helpful in preventing strokes. Another important part of this step is to allow the patient time to ask questions. When the physician and the patient are both in agreement that the information has been successfully transmitted and all questions have been answered, then a good decision can be made. Albert Camus (1913–1960) Learning objectives In this chapter you will learn: r the basic concepts of qualitative research r process for critical appraisal of qualitative research r goals and limitations of qualitative research While the evidence-based medicine movement has espoused the critical appraisal and clinical application of controlled trials and observational studies to guide medical decision making, much of medicine and health care revolves around issues and complexities not ideally suited to quantitative research. Qual- itative research is a field dedicated to characterizing and illuminating the knowl- edge, attitudes, and behaviors of individuals in the context of health care and clinical medicine. Whereas quantitative research is interested in testing hypothe- ses and estimating effect sizes with precision, qualitative research attempts to describe the breadth of issues surrounding a problem or issue, frequently yield- ing questions and generating hypotheses to be tested. Qualitative research in medicine frequently draws on expertise from anthropology, psychology, and sociology, fields steeped in a tradition of careful observation of human behavior. Unfortunately, some in medicine have an attitude that qualitative research is not particularly worthwhile for informing patient care. But, you will see that qual- itative studies can be powerful tools to expose psychosocial issues in medicine and as hypothesis-generating studies about personal preferences of patients and health-care workers. Researchers then apply one or more analytic approaches to sift through the available data to identify the main themes and the range of emotions, concerns, or approaches. In the medical literature, in-depth interviews with individuals such as patients or health-care providers and focus-group interviews and discus- sions among patients with a particular condition are the most common study designs encountered. Observations of clinical behavior and analyses of nar- ratives found in medical documents (e. Qualitative research is an appropriate approach to answering research questions about the social, attitudinal, behavioral, and emotional dimensions of health care. When the spectrum of perspectives needs to be known for the develop- ment of interventions such as educational programs or technological implemen- tations, qualitative research can characterize the barriers to and facilitators of change toward the desired practice. This can be the initial research to deter- mine the barriers to adoption of new research results in general practice. Although qualitative research studies have more methodological latitude to accommodate the wide range of data used for analysis, readers of qualitative research reports can nevertheless expect to find a clear statement of the study objectives, an account of how subjects were selected to participate and the ratio- nale behind that selection process, a description of the data elements and how they were collected, and an explanation of the analytic approach. Readers of qualitative studies should be able to critically appraise all of these components of the research methods.
Ethical problems arise when a choice has to be made on whether to consider the best outcome from the perspective of a large popula- tion or the individual patient 5mg warfarin otc. If we take the perspective of the individual patient buy discount warfarin 2 mg line, how are we to know that the treatment will benefit that particular patient, the next patient, or the next 20 patients? Is the decision up to each individual or should the decision be legislated by society? Decision trees allow the provider, society, and the patient to decide which ther- apy is going to be the most beneficial for the most people. Whether decision trees are a mathematical expression of utilitarianism is a hotly debated issue among bioethicists. The basic perspectives of medical care within the tra- ditional patient–physician relationship include medical indications, which are physician-directed, and patient preferences, which are patient-driven. Current or added perspectives modify the decision and include quality of life, which considers the impact on the individual of high-technology interventions and contextual features, which are cultural, societal, family, religious or spiritual, community, and economic fac- tors. These are all part of the discussion between the provider and the patient and form the basis of the provider–patient relationship. Assessing patient values Patient values must be incorporated into medical decision making and health- care policies by providers, government, managed care organizations, and other decision makers. The output of decision trees is variable and ultimately is based on the patient preferences. We can measure and quantify patient values and use them in decision trees to help patients make difficult decisions. Using unadjusted life expectancy or life years cannot compare various states of health in cases with the same number of years of life because they do not quantify the quality of those years. Quality-of-life scales or measures of status rated by others or by the patient themself include health status, functional sta- tus, well-being, or patient satisfaction. These Decision analysis and quantifying patient values 347 Table 30. This discussion will present sev- eral standardized quantitative measures of patient preference that can be used to measure the relative preference that a patient has for one or another outcome. The time trade-off method for this example asks “suppose you have 10 years left to live with chronic residual neurological disability from the stroke. If you could trade those 10 years for x years without any residual neurological deficit, what is the smallest number of years you would trade to be deficit-free? The patient is told to consider an imaginary situa- tion in which you will give them a pill that will instantly cure their stroke. How- ever, there is a risk in that it occasionally causes instant but painless death. On the other hand, if there were 0% cure and 100% death no one would ever take the pill unless the patient is extremely depressed and considers their life totally worthless. Continue to change the cure-to-death ratio until the person cannot decide which course of action to take. Set up a “mini decision tree” and solve for the utility of living with chronic neurological deficit. This is the value of living with a chronic stroke syndrome that the patient assigns as an outcome through a standard gamble. Different values will be obtained from each method used to measure patient values. The linear rating scale measures the quality of functionality of life, the time trade-off introduces a choice between two certainties, and the standard gamble introduces probability and willingness to take risks into the equation. Attitudes toward risk and framing effects Attitudes toward risk vary with individuals and at different periods of time during their lives. Patient values can be related to special events such as the birth of a Decision analysis and quantifying patient values 349 child or marriage, habits such as smoking or drinking, or age. The length of time involved in the trade-off will be different if asked of a younger or older person since a younger person may be less likely to be willing to trade off years. Also personal preferences related to the amount of risk a person is generally willing to take in other activities, such as sky-diving, play a role in determining patient values. Since values tend to be very personal, providers should not be the ones to assign these values. Values based on the provider’s own risk-taking behavior will not accurately measure the values of their patient. How the questions are worded or framed will influence the answer to the ques- tion. Asking what probability of death a patient is willing to accept will likely give a lower number than asking what probability of survival they are willing to accept.
Although targeted therapy drugs do not affect the body in the same way as standard chemotherapy cheap warfarin 2mg with amex, they still cause side effects order 5mg warfarin fast delivery. Some drugs target substances that are more common in cancer cells, but are also found in healthy cells. Patients often become discouraged about how long their treatment lasts or the side effects that they have. Within the concept of personalisation of treatment, it is possible to change the drug or treatment schedule if side effects are not controlled. However, in recent years, the treatment of more frequent side effects has also been improved. More patients are aware of the side events and are more informed about their disease than in the past. We can divide targeted therapies into two main categories: antibody drugs and small molecules. Antibody drugs are man-made versions of immune system proteins that have been designed to attack the external part of cells at certain targets, generally called receptors. They transmit signals from the surrounding environment to the nucleus of the cell. Targeting certain receptors means preventing the transmission of some survival signals to the tumour cells. A knowledge of the cancer characteristics and a determination of the tissue characteristics of each patient allows the doctor to select patients for the best treatment. Other examples of monoclonal antibodies are cetuximab and panitumumab, which have been developed to treat colon cancer. At frst it seemed as if these drugs were a failure, because they did not work in many patients. This is another excellent example of using individual tumour genetics to predict whether or not a treatment will work. In the past, the oncologist would have had to try each therapy on every patient and then change the therapy if the cancer continued to grow. Since antibodies are large molecules, this other type is called “small-molecule” targeted therapy drugs. Also, in this case, the small molecules prevent the broadcast of vital signals that regulate the survival of the tumour. There are several examples of targeted drugs that changed the natural history of some cancers. Imatinib targets abnormal proteins, or enzymes, that form on and inside cancer cells and promote uncontrolled tumour growth. These receptors are found on the surface of many normal cells, but certain cancer cells have many more of them. However, geftinib does not work in all patients when trying to treat lung cancer, but only in a particular subtype. Geftinib is able to switch off this signal and to stop cell growth in this subtype of patients. Unfortunately, these mutations are rare and they are mainly present in never-smokers, who are the minority of patients. By doing all of this, sunitinib slows cancer growth and stops tumours from creating their own blood vessels to help them grow and metastasise. In this case, no biomarkers have been identifed to help select patients who are responders from patients who are nonresponders. The Challenges of Genetic Marker Testing Requirements One of the worries I have as a patient advocate is that personalised medicine could become exclusive medicine when targeted therapies could create “haves” and “have nots” based on whether a patient’s genetic profle is favourable to a particular therapy being developed. So we need to ensure that academic institutions and industry are incentivised to develop innovative medicines to treat the “have nots” as well as the “haves” who, through no fault of their own, may fnd themselves with no treatment options at all, based on their genetic characteristics. Group member We also need to ensure that diagnostics are consistently accurate from lab to lab and centre to centre, so that no patient is denied a therapy on the basis of an inadequately validated assay. After targeted somatic mutation testing, more extended testing is performed in a research environment. Test results are shared with the treating oncologists, and validation of research fndings is pursued if any clinically relevant research fndings are found. Informed consent for molecular testing (depending on the clinical scenario, it could be upfront Archival block testing or at time of disease requested relapse). In the last few years, many new alterations have been identifed and specifc targeted agents to each of them are under investigation, with promising results. The hope for the Human Genome Project is to personalise treatment through identifying the best targeted drug for each single alteration.